Cigna prior authorization, page 21

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
64479*	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64480*	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64483*	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64484*	Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64490*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64491*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64492*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64493*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64494*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level	Master Precertification List For Health Care Providers, Pg 52 Original policy
64495*	Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64510*	Injection, anesthetic agent; stellate ganglion (cervical sympathetic)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64520*	Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64553*	Percutaneous implantation of neurostimulator electrode array; cranial nerve	Master Precertification List For Health Care Providers, Pg 52 Original policy
64555*	Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64567*	Percutaneous electrical nerve field stimulation, cranial nerves, without implantation	Master Precertification List For Health Care Providers, Pg 52 Original policy
64568*	Open implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator	Master Precertification List For Health Care Providers, Pg 52 Original policy
64575*	Open implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)	Master Precertification List For Health Care Providers, Pg 52 Original policy
64582*	Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array	Master Precertification List For Health Care Providers, Pg 52 Original policy
64590*	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver	Master Precertification List For Health Care Providers, Pg 52 Original policy
64596*	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array	Master Precertification List For Health Care Providers, Pg 52 Original policy
64597*	Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array	Master Precertification List For Health Care Providers, Pg 53 Original policy
64611	Chemodenervation of parotid and submandibular salivary glands, bilateral	Master Precertification List For Health Care Providers, Pg 53 Original policy
64612	Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)	Master Precertification List For Health Care Providers, Pg 53 Original policy
64615	Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)	Master Precertification List For Health Care Providers, Pg 53 Original policy
64625*	Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)	Master Precertification List For Health Care Providers, Pg 53 Original policy
64628*	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral	Master Precertification List For Health Care Providers, Pg 53 Original policy
64629*	Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral	Master Precertification List For Health Care Providers, Pg 53 Original policy
64633*	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint	Master Precertification List For Health Care Providers, Pg 53 Original policy
64634*	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint	Master Precertification List For Health Care Providers, Pg 53 Original policy
64635*	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint	Master Precertification List For Health Care Providers, Pg 53 Original policy
64636*	Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint	Master Precertification List For Health Care Providers, Pg 53 Original policy
64654*	Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distant subcutaneous pocket (ie, total system), and intraoperative interrogation and programming	Master Precertification List For Health Care Providers, Pg 53 Original policy
64714*	Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus	Master Precertification List For Health Care Providers, Pg 53 Original policy
64910*	Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve	Master Precertification List For Health Care Providers, Pg 53 Original policy
64912*	Nerve repair; with nerve allograft, each nerve, first strand (cable)	Master Precertification List For Health Care Providers, Pg 53 Original policy
64913*	Nerve repair; with nerve allograft, each additional strand	Master Precertification List For Health Care Providers, Pg 53 Original policy
64999*	Unlisted procedure, nervous system	Master Precertification List For Health Care Providers, Pg 53 Original policy
65710*	Keratoplasty (corneal transplant); anterior lamellar	Master Precertification List For Health Care Providers, Pg 53 Original policy
65760*	Keratomileusis	Master Precertification List For Health Care Providers, Pg 53 Original policy
65772*	Corneal relaxing incision for correction of surgically induced astigmatism	Master Precertification List For Health Care Providers, Pg 53 Original policy
65785*	Implantation of intrastromal corneal ring segments	Master Precertification List For Health Care Providers, Pg 53 Original policy
66174*	Transluminal dilation of aqueous outflow canal (eg, canaloplasty); without retention of device or stent	Master Precertification List For Health Care Providers, Pg 53 Original policy
66175*	Transluminal dilation of aqueous outflow canal (eg, canaloplasty); with retention of device or stent	Master Precertification List For Health Care Providers, Pg 53 Original policy
66179*	Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft	Master Precertification List For Health Care Providers, Pg 53 Original policy
66183*	Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach	Master Precertification List For Health Care Providers, Pg 53 Original policy
66683*	Implantation of iris prosthesis, including suture fixation and repair or removal of iris, when performed	Master Precertification List For Health Care Providers, Pg 53 Original policy
66999*	Unlisted procedure, anterior segment of eye	Master Precertification List For Health Care Providers, Pg 53 Original policy
67299*	Unlisted procedure, posterior segment	Master Precertification List For Health Care Providers, Pg 53 Original policy
67900*	Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)	Master Precertification List For Health Care Providers, Pg 54 Original policy
67901*	Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)	Master Precertification List For Health Care Providers, Pg 54 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

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